Thursday, 4 December 2014

Life Post DBT therapy - self help or no help?

Since being discharged from Mental Health Services in the summer, my work as a Church Mental Health volunteer has exposed me to responses to impending discharge that are different from my own. Again and again, I have encountered an expressed need to continue in a 'safe', supported environment. Usually, this has resulted in people seeking to develop and/or join peer support groups. For those who have gone through hospitalisation and intensive group therapy, there is a shared experience and understanding of certain conditions which makes peer support highly desirable. I myself have found the online peer support available through twitter and blogs to be invaluable in my ongoing DBT practice.

Certain websites have been a real help too, by providing encouragement, advice and practice from other DBT graduates. In particular, is an excellent resource. I have found the following article about 'The Self Help Myth' has challenged a number of assumptions I have made about the need for ongoing contact with 'peers' following graduation from the main DBT programme: The article presents an interesting discussion of both the problems and solutions to the self help conundrum:

"When we first presented this idea [of a Peer Led Graduate Group] to Marsha Linehan, she told us right away that it wouldn't work because of the nature of BPD (or people with similar types of diagnosis'). People with BPD have trouble with boundary confusion as well as inappropriate behaviors when triggered by stories similar to their own and have the tendency to be addicted to crisis. We balked at this response, certain that we could make it work anyway if all the participants were focused on a goal.

But Marsha was correct. The boundaries required for leadership were outside the skill set of group members. Triggering behavior often required professional intervention. Plus, when feelings were hurt or when someone felt panic, we were unable to provide the kind of validation offered by professionals. In a peer-led situation without training it was unrealistic to ask our leaders to rise above their own lives and issues in order to exert control of the group. We even tried creating a set of rules and circumstances and guidelines that groups would have to follow. But truly, the nature of the diagnosis is ill-suited to a peer-led environment."

Helpfully, DBT participants in the USA have had a number of years to develop thinking and experience about DBT so they have tried, failed and tried again to find a way forward. It is encouraging that the same website has followed the progress of different post DBT groups in the USA which seem to be having more success. However, nearly all have had the active participation of Mental Health professionals.

My attitude to peer support has been different to some. Because I belong to a strong faith community outside of the therapeutic setting, the main aim of my development of skills, has been to allow me to build a strong social network in 'the real world'. I found the protective environment of services to be a haven to which I could retreat when I was struggling to learn and practise the DBT skills when they were new to me. For some time now, I have felt it's time to move outside of that 'safe zone'.

For me, it was crucial to keep my focus on what a 'meaningful life' looked like. That included being able to build and maintain relationships that were not dependent on a shared experience of mental illness. Although, I know that most of my new friends have had a willingness to learn about my condition and the skills that help me manage it, so I have learned that some other people outside Mental Health services, are prepared to accept me as I am. Some of my former friends have never been able to reconcile themselves to the reality of my ongoing emotional and psychological struggles and I have had to accept that they are lost to me. That has allowed me to practice the DBT skill of Radical Acceptance.

If my therapy and recovery only work in helping me develop relationships with people who struggle with the same diagnosis, or with the people who work in those settings, then that is not allowing me to develop a balanced social life. I think that this issue is shared across all mental health conditions. Stigma and the fear of rejection, naturally mean that people will gravitate to 'safe' places and people. Unfortunately, the structure of services in the past has kept people in a cycle of discharge, relapse and return to 'safe' therapeutic settings. Perhaps, this goes some way to explaining the revolving door experience of people with BPD.

Having said that, there is a need for a stepped progression from group therapy towards life after discharge. Peer support clearly has a part to play in that progress. I think that peer support works if it keeps me focused on the positive practice of my DBT skills. If I can 'recharge' my mindfulness batteries ready to return to the world outside. If I am encouraged by my peers to keep developing the skills which will enhance my life and help me to build a 'life worth living'.

These concerns were foremost in my mind when I wrote a short five week programme for our church. Finally, working alongside the Vicar we developed a series of workshops aimed at helping people coming out of Mental Health services, to integrate into the community. It is not designed to be an ongoing support group, but can help by introducing people with similar experiences, although mostly a range of diagnoses from Bipolar Disorder to Anxiety and Depression. I have found that initially people were disappointed that it wasn't a 'support group', but in the last year that we have been running it, group members have developed positive friendships within the groups which have continued after they have completed the course. In addition a number have been happy to introduce others to the course and have themselves ended up helping me to run public events, such as our Suicide Awareness Day in November.

I know some people reading this will disagree with this approach. Everyone's experience is different. The pace of recovery and progress out of services varies according to each person's experience. I don't legislate for anyone else, but, for me, the growing sense of confidence in my day to day DBT practice as well as my growing social life is a testament to the fact that moving out of my safe zone has been positive for me.